Article

Risk Factors for Depression

Among Elderly Community Subjects:
A Systematic Review and Meta-Analysis

Martin G. Cole, M.D., F.R.C.P.(C.)
Nandini Dendukuri, Ph.D.
Objective: The goal of this study was to
determine risk factors for depression
among elderly community subjects.
Method: MEDLINE and PsycINFO were
searched for potentially relevant articles
published from January 1966 to June
2001 and from January 1967 to June
2001, respectively. The bibliographies of
relevant articles were searched for addi-
tional references. Twenty studies met the
following six inclusion criteria: original re-
search reported in an English or French
publication, study group of community
residents, age of subjects 50 years or
more, prospective study design, examina-
tion of at least one risk factor, and use of
an acceptable definition of depression.
The validity of studies was assessed ac-
cording to the four primary criteria for
risk factor studies described by the Evi-
dence-Based Medicine Working Group. In-
formation about group size at baseline
and follow-up, age, proportion of men,
depression criteria, exclusion criteria at
baseline, length of follow-up, number of
incident cases of depression, and risk fac-
tors was abstracted from each report.
Results: Follow-up of the inception co-
hort was incomplete in most studies. In
the qualitative meta-analysis, risk factors
identified by both univariate and multi-
variate techniques in at least two studies
each were disability, new medical illness,
poor health status, prior depression, poor
self-perceived health, and bereavement.
In the quantitative meta-analysis, bereave-
ment, sleep disturbance, disability, prior
depression, and female gender were sig-
nificant risk factors.
Conclusions: Despite the methodologic
limitations of the studies and this meta-
analysis, bereavement, sleep disturbance,
disability, prior depression, and female
gender appear to be important risk fac-
tors for depression among elderly com-
munity subjects.

(Am J Psychiatry 2003; 160:11471156)

M ajor depression occurs in 1% to 3% of the general

elderly population (1, 2), and an additional 8% to 16% have
clinically significant depressive symptoms (1, 3). The prog-
nosis of these depressive states is poor. A meta-analysis of
outcomes at 24 months estimated that only 33% of sub-
jects were well, 33% were depressed, and 21% had died (4).
Moreover, studies of depressed adults (5, 6) indicate that
those with depressive symptoms, with or without depres-
sive disorder, have poorer functioning, comparable to or
worse than that of people with chronic medical conditions
such as heart and lung disease, arthritis, hypertension, and
diabetes (7). In addition to poor functioning, depression
increases the perception of poor health (7), the utilization
of medical services (8), and health care costs (9).
The preceding findings suggest that depression in el-
derly community subjects is a serious problem. Nonethe-
less, probably fewer than 20% of cases are detected or
treated (2, 4). Even among those detected and treated, the
effectiveness of interventions appears to be modest (10).
Escalating health care costs and shrinking health care re-
sources challenge health care professionals to find more
effective and less expensive approaches to depression in
the elderly.
The success of a program for preventing delirium among
elderly medical inpatients (11) offers hope that a similar
intervention model may be useful in preventing depres-
sion among elderly community subjects. This program in-
volved identification of elderly medical inpatients with at
least one of six targeted risk factors for delirium and im-
plementation of standardized intervention protocols for
each of the risk factors present. The program attenuated
the risk factors and reduced the incidence of delirium by
40%. To develop a similar intervention model for prevent-
ing depression among elderly community subjects, risk
factors for depression in this population must be defined.
Thus, the purpose of this investigation was to determine
risk factors for depression among elderly community sub-
jects by systematically reviewing original research on this
topic. The review process, modified from the one de-
scribed by Oxman et al. (12), involved systematic selection
of articles, assessment of validity, abstraction of data, and
qualitative and quantitative synthesis of results.

Am J Psychiatry 160:6, June 2003 1147

DEPRESSION IN THE ELDERLY

TABLE 1. Prospective Studies of Risk Factors for Depression Among the Elderly

Length of Cases of Incident

Number of Subjects Age (years) % Criteria for Exclusion Criteria Follow-Up Depression
Study Baseline Follow-Up Range Mean Male Depressiona at Baselinea (months) N %
Phifer and Murrell, 2,937 1,233 55 68 41 CES-D Scale CES-D Scale score >16; 6 66 5.4
1986 (15) score >20 psychiatric
treatment in past 6
months
McHorney and Mor, 1,754 1,447 58 28 RDC 34 285 19.7
1988 (16)
Kennedy et al., 1990 1,243 1,243 65 74 46 CES-D Scale CES-D Scale score >16 24 163 13.1
(17) score >16 plus
5 points above
baseline
Harlow et al., 1991 600 445 6575 0 CES-D Scale 12
(18)
Russell and 301 284 65 40 Zung Poor health, 12
Cutrona, 1991 (19) Depression psychiatric
Scale treatment in past 6
months, dementia,
institutionalization
Green et al., 1992 1,070 65 GMS-AGECAT GMS-AGECAT 36 44 4.1
(20) criteria (level depression (level
3.5) 3+)
Livingston et al., 705 524 65 75 37 Short CARE 24 22 4.2
1993 (21) (clinical
depression
criteria)
Mendes de Leon 1,046 731 65 73 65 CES-D Scale 36 77 10.5
et al., 1994 (22) score >20
Beekman et al., 340 238 5589 50 CES-D Scale Depression, MMSE 12 38 16.0
1995 (23) score >16 score <16
Zeiss et al., 1996 680 50 41 CES-D Scale Depression 24 95 14.0
(24) score >12 plus
SADS criteria
Kivela et al., 1996 944 679 60 69 41 DSM-III criteria Depression 60 60 8.8
(25)
Prince et al., 1998 538 383 65 76 39 Short CARE Depression 12 46 12.0
(26) (pervasive
depression
criteria)
Turvey et al., 1999 5,449 70103 77 38 Modified CES-D 24 327 6.0
(27) Scale score >6
CIDI criteria 24 193 3.5
Livingston et al., 141 79 6595 23 Short CARE Limitations in 36 19 24.1
2000 (28) (depression activities of daily
homogeneous living, depression,
scale positive) dementia
Schoevers et al., 3,747 1,940 6584 38 GMS-AGECAT Depression, dementia 36 309 15.9
2000 (29) criteria (level
3.5)
Geerlings et al., 325 234 5585 69 48 CES-D Scale Depression 36 33 14.1
2000 (30) score >16 plus
5 points above
baseline
Forsell, 2000 (31) 1,777 903 75 85 23 DSM-IV criteria Depression, anxiety, 36 29 3.2
psychosis
Paterniti et al., 2000 1,191 1,014 5971 65 41 CES-D Scale Depression 24 64 6.3
(32) score >16 for
men and >22
for women
Roberts et al., 2000 2,370 2,228 5095 65 44 DSM-IV criteria Depression 12
(33)
Kritz-Silverstein 2,029 944 5089 71 46 BDI score >13 Severe depression, 96 17 1.8
et al., 2001 (34) disability
a CES-D Scale: Center for Epidemiologic Studies Depression Scale. RDC: Research Diagnostic Criteria. GMS-AGECAT: Geriatric Mental State Sched-
ule Automated Geriatric Examination for Computer Assisted Taxonomy. Short CARE: shortened Comprehensive Assessment and Referral Eval-
uation. MMSE: Mini-Mental State Examination. SADS: Schedule for Affective Disorders and Schizophrenia. CIDI: Composite International Di-
agnostic Interview. BDI: Beck Depression Inventory.

1148 Am J Psychiatry 160:6, June 2003

 MARTIN G. COLE AND NANDINI DENDUKURI

Method TABLE 2. Validity of Prospective Studies of Risk Factors for

Depression Among the Elderly According to Four Criteriaa
Selection of Articles Sufficient
Follow-Up
The selection process involved four steps. First, two computer
Long
databases, MEDLINE and PsycINFO, were searched for potentially Enough Complete
relevant articles published from January 1966 to June 2001 and Similar Same Interval Data
from January 1967 to June 2001, respectively. For MEDLINE, the Comparison Measure of (12 (80% of
key words depression, risk factor, and aged and the text word Study Groups Depression months) subjects)
community were used; for PsychINFO, the same words were Phifer and Murrell,
1986 (15) + +
used as text words. Second, relevant articles (judged on the basis
McHorney and Mor,
of the title and abstract) were retrieved for more detailed evalua- 1988 (16) + + +
tion. Third, the bibliographies of relevant articles were searched Kennedy et al., 1990
for additional references. Finally, all retrieved articles were (17) + + + +
screened to determine which met the following six inclusion cri- Harlow et al., 1991
(18) + + +
teria: 1) original research published in English or French, 2) study
Russell and Cutrona,
group of community residents, 3) subjects age 50 years or older, 1991 (19) + + + +
4) prospective design that excluded subjects who were depressed Green et al., 1992
at baseline (or controlled for baseline depression in the analysis), (20) + + +
5) study of at least one risk factor for depression, and 6) acceptable Livingston et al.,
1993 (21) + + +
definition of depression (either recognized diagnostic criteria or
Mendes de Leon
cutoff on a depression rating scale). et al., 1994 (22) + + + +
Beekman et al.,
Assessment of Validity 1995 (23) + + +
Zeiss et al., 1996 (24) + + +
To determine validity, the methods of each study were as-
Kivela et al., 1996
sessed according to the four primary criteria for risk factor stud- (25) + + +
ies described by the Evidence-Based Medicine Working Group Prince et al., 1998
(13): 1) clearly identified comparison groups that were similar (26) + + +
with respect to important determinants of outcome, other than Turvey et al., 1999
(27) + + +
the one of interest (or analysis that controlled for differences in
Livingston et al.,
important determinants), 2) measurement of exposures and out- 2000 (28) + + +
comes in the same way, 3) a sufficiently long follow-up (i.e., 1 Schoevers et al.,
year), and 4) a sufficiently complete follow-up (i.e., including 2000 (29) + + +
80% of inception cohort). Each study was scored with respect to Geerlings et al., 2000
(30) + + + +
meeting (+) or not meeting () each of the these criteria.
Forsell, 2000 (31) + + +
Paterniti et al., 2000
Abstraction of Data (32) + + + +
Information about the size of the study group at baseline and Roberts et al., 2000
(33) + + + +
follow-up, subjects age, proportion of men, criteria for depres-
Kritz-Silverstein
sion, exclusion criteria at baseline, length of follow-up, number of et al., 2001 (34) + + +
incident cases of depression, and risk factors was abstracted from a The four primary criteria for risk factor studies described by the Ev-
each report. idence-Based Medicine Working Group (13). A plus sign indicates
the study met the criteria; a minus sign indicates the study did not
Data Synthesis meet the criteria; a dash indicates fulfillment of the criteria could
not be determined.
Qualitative. All abstracted information was tabulated. A quali-
tative meta-analysis was conducted by summarizing, comparing,
and contrasting the abstracted data. Results
Quantitative. A quantitative meta-analysis was conducted for
risk factors with usable data from two or more studies. To obtain Selection of Articles
a pooled estimate of the odds of depression associated with The search strategy yielded 130 potentially relevant
each risk factor, we conducted a meta-analysis using a Bayesian
studies; 45 were retrieved for more detailed evaluation.
hierarchical (random effects) model (14). In the Bayesian frame-
work, information available before the analysis is combined
Twenty studies (1534) met the inclusion criteria (Table 1).
with the observed data to obtain a posterior distribution for the The other 25 studies were excluded for the following rea-
parameters of interest (14). We assumed no prior information sons: four did not meet the age criterion, 16 were not pro-
was available. The variance between odds ratios from different spective, two did not study at least one risk factor, and
studies is a measure of the heterogeneity of the studies. A Baye-
three did not meet two or more of the inclusion criteria.
sian 95% posterior credible interval may be interpreted in a
straightforward manner as an interval that contains the param- Assessment of Validity
eter of interest with 95% probability given the observed data. We
also estimated the probability that the pooled odds ratio was Six studies met all of the criteria. Most studies had in-
greater than 1. complete follow-up of the inception cohort (Table 2).

Am J Psychiatry 160:6, June 2003 1149

DEPRESSION IN THE ELDERLY

TABLE 3. Findings on Risk Factors for Depression Among the Elderly From Univariate Analysis of Prospective Studies a
Poor New Poor
Social Medical Health Sleep Prior Less Cognitive
Study Disability Older Female Support Illness Status Disturbance Depression Education Unmarried Bereavement Impairment
Phifer and
Murrell,
1986 (15) 0 0 0 0
McHorney
and Mor,
1988 (16) + +
Kennedy
et al.,
1990 (17) + + + 0 + + + 0
Harlow
et al.,
1991 (18) + + + + + +
Russell and
Cutrona,
1991 (19) +
Green et al.,
1992 (20) 0 0 0 0 0 0 0 0
Livingston
et al.,
1993 (21) +
Mendes
de Leon
et al.,
1994 (22) +
Beekman
et al.,
1995 (23) + 0 0 + 0 0
Zeiss et al.,
1996 (24) + 0
Kivela et al.,
1996 (25) 0 0 0 0 0
Prince et al.,
1998 (26) + + + +
Turvey
et al.,
1999 (27) 0 0 0
Livingston
et al.,
2000 (28) 0 0 0 0 0 0
Schoevers
et al.,
2000 (29) + + 0 0 + + + 0 0 + 0
Geerlings
et al.,
2000 (30) + +
Forsell,
2000 (31) + 0 0 0 0 + + 0 +
Paterniti
et al.,
2000 (32)
Roberts
et al.,
2000 (33) + + + + + + 0
Kritz-
Silverstein
et al.,
2001 (34)
Number of
studies 11 11 10 8 6 6 7 6 7 7 4 5
Number of
positive
studies 10 4 2 3 4 4 5 3 3 0 2 2
a A plus sign indicates a risk factor; a minus sign indicates a protective factor; zero indicates the factor had no effect of either type; blank cells
indicate the factor was not studied. Each of the risk factors shown was examined in two or more studies. Risk factors examined in one study
each were poor locus of control, more daily hassles, poor life satisfaction, loneliness, pain, family illness, more neuroticism, more extrover-
sion, limitations in instrumental activities of daily living, new limitations in instrumental activities of daily living, religion unimportant,
absence of a pet, lower social class, low exercise level, immigrant status, childlessness, and financial problems.

1150 Am J Psychiatry 160:6, June 2003

 MARTIN G. COLE AND NANDINI DENDUKURI

Poor Self- Nonwhite Vision or Use of

New Perceived Race or Living Hearing Loss Lower More Hypnotics, Alcohol Family
Disability Health Ethnicity Institutionalized Alone Impairment Events Income Smoking Anxiety Tranquilizers Abuse Depression

+ + + 0 + 0 +

+ +

0 0 + 0 0 0 0

+ + 0 0 0

0 0

+ + 0

0 +

3 3 3 3 3 2 3 2 2 2 2 2 2

3 3 1 1 0 2 1 1 1 1 1 0 0

Am J Psychiatry 160:6, June 2003 1151

DEPRESSION IN THE ELDERLY

TABLE 4. Findings on Risk Factors for Depression Among the Elderly From Multivariate Analysis of Prospective Studies a
Poor Poor New
Health Social Medical Prior Less
Study Disability Bereavement Status Female Support Older Unmarried Illness Depression Education
Phifer and Murrell, 1986 (15) + 0 0 + 0 0 + 0
McHorney and Mor, 1988 (16) + 0 0 + +
Kennedy et al., 1990 (17) + + +
Harlow et al., 1991 (18) + + + 0
Russell and Cutrona, 1991 (19)
Green et al., 1992 (20) + + 0 0 0 0
Livingston et al., 1993 (21)
Mendes de Leon et al., 1994 (22) +
Beekman et al., 1995 (23)
Zeiss et al., 1996 (24)
Kivela et al., 1996 (25)
Prince et al., 1998 (26) + +
Turvey et al., 1999 (27) +
Livingston et al., 2000 (28)
Schoevers et al., 2000 (29) + + + +
Geerlings et al., 2000 (30) + 0
Forsell, 2000 (31) 0 0 0 0 0 0 + 0
Paterniti et al., 2000 (32)
Roberts et al., 2000 (33)
Kritz-Silverstein et al., 2001 (34)
Number of studies 7 6 5 5 5 4 4 3 3 3
Number of positive studies 6 5 3 2 1 1 0 3 2 1
a A plus sign indicates a risk factor; a minus sign indicates that the factor had a protective effect; zero indicates it had no effect of either type;
blank cells indicate the factor was not studied. Each of the risk factors shown was examined in two or more studies. Risk factors examined in
one study each were family tension, poor caretaker, length of deceased loved ones illness, new disability, low income, low life satisfaction,
loneliness, smoking, pain, limitations in instrumental activities of daily living, new limitations in instrumental activities of daily living, early
parental death, parental depression, poor locus of control, Jewish or Catholic religious attendance, cognitive impairment, alcohol abuse, liv-
ing alone, absence of pet, lower social class, institutionalization, family depression, low exercise level, anxiety, medication use (hypnotics,
tranquilizers), immigrant status, childlessness, and low blood pressure.

Data Synthesis Forty-three risk factors were studied by multivariate

Qualitative. The 20 included studies (Table 1) involved
more than 23,058 subjects at baseline, more than 20,678
subjects at follow-up, and more than 1,694 subjects with
incident depression. The numbers of subjects at baseline
and follow-up ranged from 141 to 3,747 and from 79 to
5,449 subjects, respectively. The subjects mean ages were
reported in 13 articles (mean=5885 years). Nineteen arti-
cles included gender distribution: 0%65% of subjects
were men (median=41%). The length of reported follow-
up ranged from 3 to 96 months (median=24). Nine studies
used DSM or structured interview criteria to diagnose de-
pression, nine used a cutoff on a depression rating scale,
and two used both. Among the 17 reports that included
the frequency of incident depression, the frequencies
ranged from 1.8% to 24.1% (median=12.0%) and were gen-
erally higher in studies using cutoffs on rating scales than
in those using diagnostic criteria.
Forty-two different risk factors were studied by univari-
ate analysis, 25 in two or more studies and 17 in one study
each (Table 3). Disability, being older, female gender, new
medical illness, poor health status, sleep disturbance,
prior depression, less education, cognitive impairment,
new disability, poor self-perceived health, poor social sup-
port, bereavement, and vision or hearing impairment
were identified as risk factors for depression in at least two
studies each.
analysis, 15 in two or more studies and 28 in one study
each (Table 4). Disability, bereavement, new medical ill-
ness, poor health status, female gender, prior depression,
sleep disturbance, and poor self-perceived health were
identified as risk factors for depression in at least two
studies each. Risk factors identified by both univariate and
multivariate techniques in at least two studies each were
disability, female gender, new medical illness, poor health
status, prior depression, sleep disturbance, poor self-per-
ceived health, and bereavement.
Quantitative. Only 13 risk factors had data that could be
used in the quantitative meta-analysis (Table 5 and Fig-
ure 1). The combined odds ratios ranged from 1.0 to 3.3.
Greater heterogeneity was observed among studies evalu-
ating lower education, disability, poor health status, cog-
nitive impairment, prior depression, and new medical ill-
ness as risk factors for depression. On the basis of the
combined odds ratios (and their 95% credible intervals)
and the posterior distributions of the odds ratios (pooled
odds ratio >1), the following were found to be significant
risk factors for depression: bereavement, sleep distur-
bance, disability, prior depression, and female gender.
Higher age, lower education level, being unmarried, and
poor social support did not appear to be risk factors. Poor
health, cognitive impairment, living alone, and new med-
ical illness were uncertain risk factors.

1152 Am J Psychiatry 160:6, June 2003


Poor Self- Vision or Nonwhite
Sleep Perceived Loss Hearing Race or
Disturbance Health Events Impairment Ethnicity
+
0 These five risk factors may serve two other purposes
0 + + +
+
0 0
+ The finding that bereavement is an important risk factor
0 However, it has been argued that the ECA study probably
+
4 2 2 2 2 This review has 10 potential limitations. First, the search
2 2 1 1 1
Discussion
The combined results of 20 prospective studies of risk
factors for depression among elderly community subjects
indicate that five factors (bereavement, sleep disturbance,
disability, prior depression, and female gender) are signif-
icant risk factors for depression. The median interval be-
tween the determinations of risk factor status and depres-
sion status was 24 months.
Notably, three of these risk factors are potentially modi-
fiable, namely, bereavement, sleep disturbance, and dis-
ability. Based on the pooled odds ratios data in this meta-
analysis, the attributable risks for these three risk factors
were 69.4% (95% credible interval=42.279.5), 57.0% (95%
credible interval=35.773.3), and 56.5% (95% credible in-
terval=20.483.5), respectively. Thus, a large proportion of
depression among elderly people in the community may
be attributed to one of these risk factors. Because these
risk factors are frequent in elderly community subjects,
their modification could be expected to have an important
public health impact.
Elderly populations could be screened to identify indi-
viduals at high risk of depression (e.g., bereaved women
with prior depression, disability, and sleep disturbance).
Subsequently, these individuals could be targeted for in-
terventions to abate the three potentially modifiable risk
factors and reduce the risk of depression. Such interven-
tions might include education about the significance of
the risk factors, bereavement counseling and support (35),
Am J Psychiatry 160:6, June 2003
MARTIN G. COLE AND NANDINI DENDUKURI
new skills training, maintenance of routines protocols
(36), enhancement of social supports (37), individual or
group therapy to facilitate adjustment to loss of function
(38), and sleep enhancement protocols (39).
(40). First, they could identify whole populations at high
risk of depression and aid the development of population-
based interventions to reduce the frequency of depres-
sion. Second, they could focus treatment on the most im-
portant putative contributing factors (e.g., bereavement,
loss of function, sleep disturbance).
for depression contradicts the results of the Epidemiologic
Catchment Area (ECA) study (41), which indicated low
rates of bereavement-related depression in the elderly.
failed to diagnose the low-level symptomatic forms of de-
pression experienced by many elderly (42).
of the literature was conducted by one author only. Sec-
ond, the search was limited to articles published in En-
glish or French. Third, we did not assess publication bias,
although it is unlikely that this bias influences publication
of risk factor studies. Fourth, the data were abstracted by
one author only. Fifth, follow-up of the enrolled cohort
was incomplete in most studies; however, the results of
studies with and without complete follow-up were similar.
Sixth, examination of depression status was complicated
by differences in the length of follow-up; nonetheless,
there were no consistent differences in reported risk fac-
tors by length of follow-up. Seventh, the examination of
the results of the univariate and multivariate analyses was
complicated by differences in the definitions of some risk
factors from one study to the next, and the examination of
the results of the multivariate analyses was complicated
by adjustments for different variables in different studies.
Eighth, we have identified with some confidence five fac-
tors that increase the risk of depression and four factors
(higher age, lower education level, being unmarried, poor
social support) that do not appear to increase the risk of
depression; however, many potential risk factors have not
been studied adequately. Ninth, in this meta-analysis, we
could not determine whether the simultaneous presence
of multiple risk factors results in a cumulative increase in
the risk of depression; however, the results of four studies
included in this meta-analysis (15, 18, 19, 29) suggest that
different risk factors play both additive and interactive
roles. Finally, there was heterogeneity in the results for
some risk factors (i.e., lower education level, disability,
poor health status, cognitive impairment, prior depres-
sion, new medical illness), perhaps related to different
definitions of these variables in different studies and small
study groups in some studies; consequently, the results of
the meta-analysis for these risk factors must be inter-
preted cautiously.
1153
DEPRESSION IN THE ELDERLY

TABLE 5. Results of Meta-Analysis of Prospective Studies of Risk Factors for Depression Among the Elderly
Pooled Odds Ratio Variance Between Studies Probability of Pooled
Risk Factor Posterior Median 95% Credible Interval Posterior Median 95% Credible Interval Odds Ratio >1 (%)
Older 1.2 0.91.7 0.05 <0.010.64 91
Female 1.4 1.21.8 0.01 <0.010.16 100
Less education 1.5 0.82.8 0.14 <0.012.20 95
Unmarried 1.0 0.81.3 0.01 <0.010.30 50
Disability 2.5 1.64.8 0.11 <0.011.49 100
Recent bereavement 3.3 1.74.9 0.03 <0.011.57 99
Lower social class 1.2 0.53.7 0.03 <0.015.87 80
Poor health status 1.8 0.512.8 0.14 0.0110.71 91
Cognitive impairment 2.1 0.68.6 0.39 <0.018.20 93
Sleep disturbance 2.6 1.93.7 0.02 <0.010.52 100
Living alone 1.7 0.64.7 0.03 <0.016.16 92
Prior depression 2.3 1.17.1 0.11 <0.015.13 97
New medical illness 2.1 0.410.1 0.71 0.0811.57 86

FIGURE 1. Individual and Combined Odds Ratios and 95% Credible Intervals in Prospective Studies of Risk Factors for
Depression Among the Elderly

Older Bereavement
Phifer et al. (15) Mendes de Leon et al. (22)
McHorney et al. (16) a
Livingston et al. (28)
Livingston et al. (28) Schoevers et al. (29)
Schoevers et al. (29) Turvey et al. (27)
Turvey et al. (27) Overall
Forsell (31) Poor Social Support
Roberts et al. (33) Schoevers et al. (29)
Overall Forsell (31)
Female Overall
Phifer et al. (15) Poor Health Status
Kennedy et al. (17) Schoevers et al. (29) d
Kivela et al. (25) Geerlings et al. (30)
b e
Livingston et al. (28) Overall
Schoevers et al. (29) Cognitive Impairment
Forsell (31) Prince et al. (26)
Roberts et al. (33) Schoevers et al. (29)
Overall Forsell (31)
Less Education Overall
Phifer et al. (15) Sleep Disturbance
c
Livingston et al. (28) Kennedy et al. (17) f
Schoevers et al. (29) Livingston et al. (21)
Forsell (31) Prince et al. (26)
Roberts et al. (33) Livingston et al. (28)
Overall Roberts et al. (33)
Unmarried Overall
Phifer et al. (15) Living Alone
Kennedy et al. (17) Kennedy et al. (17)
Schoevers et al. (29) Livingston et al. (28)
Forsell (31) Overall
Roberts et al. (33) Prior Depression
Overall McHorney et al. (16)
Disability Schoevers et al. (29) g
Prince et al. (26) Forsell (31)
Schoevers et al. (29) Overall
Geerlings et al. (30) New Medical Illness
Forsell (31) Kennedy et al. (17)
Roberts et al. (33) Livingston et al. (28)
Overall Schoevers et al. (29) h
Overall
0.1 0.2 0.5 1 2 3 4 5 7 10 0.1 0.2 0.5 1 2 3 4 5 7 10
Odds Ratio (log scale) Odds Ratio (log scale)
a Credible interval extends to 0.09.
b Credible interval extends to 14.9.
c Credible interval extends to 0.07.
d Credible interval extends to 11.7.
e Credible interval extends to 12.8.
f Credible interval extends to 10.5.
g Credible interval extends to 14.5.
h Credible interval extends to 10.1.

To conclude, five risk factors for depression among el- Despite the methodologic limitations of the studies and
derly community subjects include bereavement, sleep dis- this meta-analysis, these findings may guide efforts to de-
turbance, disability, prior depression, and female gender. velop programs to prevent depression in this population.

1154 Am J Psychiatry 160:6, June 2003


Received April 16, 2002; revisions received Oct. 8 and Nov. 25,
2002; accepted Dec. 2, 2002. From the Department of Psychiatry, St.
Marys Hospital and McGill University; the Department of Clinical Ep-
idemiology and Community Studies, St. Marys Hospital; and the De-
partment of Epidemiology and Biostatistics, McGill University, Mon-
treal. Address reprint requests to Dr. Cole, Department of Psychiatry,
St. Marys Hospital, 3830 Lacombe Ave., Montreal, Quebec H3T 1M5,
Canada.
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